Counselling & Mediation Services Leland Clipperton, H.S.C. 313 Maple Street, Collingwood, Ontario, L9Y 2R3 Phone: (705) 999-2107 (905) 510-9117 Email: leland@CounsellingandMediation.com Skype: counsellingandmediation
Name: ________________________________________________________ Address: _______________________________________________________ Postal Code: __________________ Phone No.:[Cell] ______________________ [Home] ________________________ [Business] _______________________ Email Address: __________________________________________________ Date of Birth: __________________ Referred by: ________________________ You have made the first step to your ongoing change process. This is often a challenging decision to make. Sometimes therapy can seem like hard work with unimaginable rewards. Much of the process involves sharing your personal thoughts and feelings. Your commitment to undertake therapy at this time in your life will be best served if you give this time the greatest value you can. There is a direct relationship between successful outcome of therapy and how strong your belief in the process is. In other words, the more value and positive belief you place on your therapy, the greater your success will be. Therapy can often feel difficult and you will likely have times when you will feel that something or someone seems to take priority over your scheduled sessions. This is typically an ideal opportunity for your own personal growth. It is often more valuable to work through this situation while in a supportive environment. Most clients whom attend regular weekly sessions find it easier to book the same time and day. ie. Wednesdays at 10:00. Sessions are 55 minutes in duration. Regular and timely attendance at all sessions is expected. You are responsible for payment of all booked and confirmed sessions. Fees are $100.00 per session for individual counselling, $120 for couples counselling, and $150.00 for mediation. Payment is required at each session. Fees are not covered by O.H.I.P. Please check with your individual insurance company for possible extended health plan coverage. Employee assistance program coverage may also be available. I have read and understand the above. Signed: ______________________________ Date:______________________________ _________________________________________________________________________________________________ Describe where you live. How long have you lived there? What do you like about where you live? What don’t you like about where you live? Who do you live with? What is like at your residence i.e. what typical conflicts occur? Describe your work (or school ) experience. What motivated you to come to therapy? What needs to occur to improve your life? What are your strengths? What are your weaknesses? Describe the problems you are currently experiencing. What are the consequences of the current problems you experience? What do you typically find rewarding i.e. people, places, things, food, activities? What do you find unpleasant i.e. people, places, things, food, activities? What is your medical history? Describe your family’s medical history (major disease, mental illness, etc.). Have you been in therapy before?If yes, please provide details. Members offamily (including spouse, parents, children, siblings, etc.)? NameAge Relationship Please describe any recurring thoughts or dreams you may have. How would you describe yourself? What will you be like when your therapy is completed?